Beyond the Addict: Keeping Countertransference in Check

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I remember the first time I came across a patient who used cocaine and heroin. My own upbringing and mores had caused me to approach such patients with trepidation. This has subsequently become a matter of daily occurrence during my residency in psychiatry.

Seeing patients repeatedly endure drug withdrawals, endocarditis, pain, infections, ICU admissions, abscesses, and surgical procedures did not make sense. Why was it not obvious to them (as it was to me) that drug use was harmful? Why didn’t they stop?

No amount of information about the dangers of drugs made any difference. It was frustrating that our efforts to detox these patients and provide them with follow-up appointments, medications, and counseling proved useless. I had no clue why this approach was not working. It was not a matter of lack of education or resources. There was a resistance to getting better.

Soon I moved to my rotation in psychiatry inpatient units. In Detroit, this meant a majority of dual-diagnosis cases. The unit was a revolving door for many patients with substance abuse issues and comorbidity was a major hindrance to their recovery. No amount of antidepressants and antipsychotics to alleviate their symptoms would benefit these patients because the core issue for continuing substance abuse was not being addressed.

Then came an experience in my rotation in addiction psychiatry. One of the attending physicians that I worked with had a new approach. During interviews with patients, we began asking about past traumas. In most cases, these traumas had triggered the beginning of drug abuse “to kill the pain,” as one put it.

Another patient had been abusing cocaine and heroin for 20 years and now, at age 35, he expressed a desire to be a better role model for his children: “I don’t want them to be like me,” he told me. His mother moved away from his abusive father when he was 6 years old. He was later physically abused and throughout his childhood was told by his mother “you are just like your father” because he looked like his father and reminded her of her past.

Without knowing this patient’s history or that he had a long family history of drug abuse, it would have been difficult to understand why he had such a hard time abstaining from drug use and easy to assume that every patient does this to himself willingly. The patient’s self hatred as a result of the verbal abuse he had been subjected to in childhood was one of the key contributors to his substance abuse. With therapy, the patient began to believe that he was worth something and that he could feel good about himself.

Some research shows that addiction is similar to many other chronic illnesses such as hypertension or diabetes, where continued care is needed and the course is one of remissions and relapses.1 We need to keep our countertransference in check and not let a relapse of addiction make us so disillusioned that we stop trying.

Medicine is not about making us feel better about ourselves—although this doesn’t hurt. In the case of addicts, it is about looking at the root cause of addictions and seeing the person—not just the addict—in front of us.